A practical nurse enters a client's room and observes the client coughing vigorously with enteral nutrition formula visible in their mouth. The client is currently receiving a continuous enteral tube feeding. In which order should the nurse perform the following actions to minimize the risk of aspiration and respiratory complications? Arrange the steps from first to last.
- 1Stop the continuous enteral feeding pump immediately.
- 2Turn the client to a side-lying position.
- 3Suction the client's oropharynx to clear the formula.
- 4Obtain vital signs, including oxygen saturation.
- 5Notify the supervising registered nurse (RN) of the event.
Answer
The nurse must first stop the enteral feeding pump, turn the client to a side-lying position, suction the oropharynx, obtain vital signs including oxygen saturation, and finally notify the supervising RN.
In any acute clinical emergency, the nurse must follow the principles of priority setting: address the immediate threat to life first. When a client receiving tube feedings begins to aspirate, the nurse must instantly stop the source of the aspiration (the pump). Following the ABCs (Airway, Breathing, Circulation), the nurse then physically protects the airway by turning the client, followed by clearing the airway via suction. Only after the airway is stable should the nurse assess breathing parameters (vital signs/oxygen saturation) and escalate the findings to the RN.
Step-by-Step Solution
Key Concept
Immediate airway management and sequence of prioritization during an aspiration event
Estimated Time:1m 15s